Suicide

DefinitionsSuicide: intentional self-inflicted deathSuicidal ideation: thoughts of killing

oneself (i.e., serving as the agent of one’s death)

Suicidal act: intentional self-injury (can have varying degrees of lethal intent)

IntroductionSuicidal behaviors are the most

common psychiatric emergencyThe 11th leading cause of death in U.S.

(2001)About 30,000 suicides annually in U.S.Over 90% of suicide victims have a

diagnosable psychiatric disorder—over half have a depressive disorder

Attempts vs. Completions

Ratio of attempts to completions may be as high as 25:1

Women more likely to attempt suicideMen more likely to complete suicide Men use more lethal means

Psychopathology isthe primary underlying risk factor

Major depressionBipolar disorder SchizophreniaSubstance use disordersPersonality disorders: borderline,

antisocialPanic disorder

Highly important underlying risk factors

History of previous attemptsDepressionAlcohol or drug abuse

Other underlying risk factorsHistory of psychiatric hospitalizationChronic medical illnessFamily history of suicideHistory of childhood abuse (physical,

verbal, or sexual)Impulsiveness

Underlying sociodemographic risk factors

Social isolation:-Living alone-Not currently married (never married, separated, divorced, or widowed)

UnemploymentMale genderIncreased age (among white men)Certain occupations: police officers,

physicians

Proximal Risk Factors

IntoxicationStressful life events:

-loss of job-death of a loved one-divorce-migration-incarceration

Are suicides more frequent around the holidays?

Firearms greatly increase the risk of completed suicide

Presence of a gun in the home increases risk of suicide 5X

Readily accessible firearms facilitate lethal impulsive acts and leave little chance for rescue

70-90% fatality rate for suicidal firearm injuriesWomen’s use of firearms has risen dramatically—

now firearms are leading method of completed suicide by women in U.S.

Most common methods of completed suicide

Men

1. Firearms (61%)2. Hanging

Women

1. Firearms (37%)2. Self-poisoning

Psychological factors/theories

Hopelessness, despair, desperationFreud: aggression turned inwardEscape from rageGuilt; self-punishment or atonementRebirth or reunion fantasiesControl over a relationshipRevenge

Religion and SuicideLower rates among Jews and Catholics,

presumably due to religious prohibitionLower rates in predominately Catholic countries,

but this is not consistentReligious affiliation is apparently less important

than religious involvement and participation in affecting risk of suicide

Suicide and Schizophrenia (I)33-50% with schizophrenia will attempt suicideApproximately 10% with schizophrenia die by

suicideGender: equal attempt ratio, more men die by

suicideIsolation (single, living alone, unemployed)Substance abuseAkathisia

Suicide and Schizophrenia (II)Periods of increased risk:

Highest risk in first 10 years of illnessWhen depressionWhen hopeless After resolution of an acute psychotic exacerbationDays, weeks, months after hospitalization

Persons with more “insight” thought to be at higher risk of suicide

Suicide among physiciansRate higher than general population, particularly for

women doctors (same rate in male, female MDs)Unrecognized and untreated depression a common

themePhysician help-seeking highly suboptimal:

1/3 of physicians have no regular doctorLow rates of seeking help for depressionProfessional attitudes discourage admission of health

vulnerabilitiesConcerns about confidentiality, licensing, privileges, medical

insurance, malpractice insuranceWhen seek help often quite ill

Assessment of suicidality

Ask about suicidality in every initial psychiatric assessment

Asking about suicidality does not suggest itDo not dismiss someone’s suicidal

commentsSpectrum of suicidality: passive thoughts,

plan, intent, attemptIntent is not always communicatedNo absolute predictive test or criteria

When assessing suicide risk, consider:Pervasiveness of thoughtsPlan Lethality of plan/attemptAvailability of lethal meansLikelihood of rescue

Markers of increased suicide riskPreparations for death: Settling affairs, giving

away personal items, writing a noteSudden change of moodLack of future plansRecent lossSymptoms: Insomnia, hopelessness, severe

anxiety, extreme restlessness or agitation

Management of suicidal patientsDetermine treatment setting: Inpatient or

outpatientCaution regarding “contracts for safety”MedicationsLimit availability of firearms, lethal drugs, other

meansAccess to crisis services neededTherapy

Regarding risk factors for suicide

Risk factors alone or in combination do not allow accurate prediction of a specific individual’s suicide

However, knowledgeable assessment of risk and protective factors can allow estimation of an individual’s risk and can be used to formulate a plan to reduce the risk of suicide

What every doctor and nurse should know about suicideDepression is the most common diagnosis

associated with suicide: recognize it, treat or refer

Do not ignore suicidal comments, threatsAsking about suicide does not suggest itThe 3 most important risk factors: history of

suicide attempts, depression, substance abuse